Nurse practitioners: the slow resurrection of a good idea
INTRODUCTION
NURSE PRACTITIONERS: FROM DEATH TO LIFE
Spitzer (1984) once published a paper on the seemingly hopeless resuscitation of a dying nursing role that has proven to be of great worth to the healthcare in Canada. In his article, The Nurse Practitioner (NP) Revisited: The slow death of a good idea, he expressed grief on the death of great plans, programs and opportunities for the Nurse Practitioner roles (Spitzer, 1984). He adds also a forecast of the role not being able to resurge again in the future (Spitzer, 1984).
However, this prediction seems to be contradicted by today’s burgeoning interest for NP’s. Aside from Canada, United States, and United Kingdom, Australia is showing interest for the roles of NP’s in its healthcare system (Brown & Tarlier, 2008). The following discussions take us into studying more the rise of NP practice in Australia but with considerations for the conditions of the role’s development in the other aforementioned countries and ultimately the feasibility of the emerging nursing role in Australia’s healthcare and socio-political system.
The Development of Nurse Practitioner Roles in Australia
After more than a decade of struggle, New South Wales (NSW), through its Nurse Practitioner Project in 2002, was able to give rise and defend the nurse practitioner title through legislative measures (Pearson & Peels, 2002) with the first Australian NP coming from Wanaaring, NSW (Turner, Keyzer, & Rudge, 2007). Thus, this paved the way for the rise of NP practice in four other states, namely: South Australia; Victoria; Capital Territory; and Western Australia (Gardner, 2004).
Nonetheless, the initiative made by the Nursing regulators of NSW is not the sole reason for the increasing growth of the NP roles in Australia. Much of this is due to the increasing need for the foreseen benefits of adapting such a practice.
Literature has long confirmed the ability of NP’s to provide high quality and cost-effective care that is highly valued by the various healthcare stakeholders – the investors, policy-makers, other healthcare providers, and patients (Shum et al., 2000; Buchan & Calman, 2004). Also, with the reality of communities that have low access to healthcare due to remoteness of living, low socio-economic status, and reluctance of medical professionals to accept rural assignments, NP’s are seen as the solution for this diversified healthcare (Pearson & Peels 2002). NP’s humanize the healthcare system by working where other healthcare professionals are unwilling, unprepared, or unavailable (Brown & Tarlier, 2008). Thus, NP’s are the cost-efficient solution to healthcare systems that aspires for a quality and an all-out reaching healthcare provision, like that in Australia.
The definition of a nurse practitioner differs from one country to another or from one state to that of another state. In the Government of New South Wales (New South Wales Health Department, 1998, p. 23), the nurse practitioner is defined as:
“… a registered nurse with appropriate accreditation who practices within the professional role. S/he has autonomy in the work setting and has freedom to make decisions consistent with his/her scope of practice, and the freedom to act on those decisions.”
These autonomous decisions are considered to comprise of dispensing medications from pharmacy, taking x-rays, assessment and diagnosis of patients, admission and discharge of patients, intubations and other emergency care, counseling and other social worker skills (Pearson & Peels, 2002). With these increased accountability, NP’s are therefore required to undertake advanced educational preparations that will equip them for the responsibilities that are well beyond traditional nursing roles (New South Wales Health, 2005).
Thus, with these established beneficial roles of NP’s and their growing practice in Australia, one can easily see ahead the bright future that awaits this practice (Pearson & Peels, 2002). Yet, considering how Spitzer’s notes on the Canadian experience of giving birth and death to NP roles shows socio-politics’ effects the long-term sustainability of NP roles. Therefore, this study will aim to look at the socio-political aspects that affect NP roles and how changes can be made so that the NP practice and the benefits it bring can be maintained on a steady development.
DISCUSSION
NP’S AND SOCIO-POLITICS: THE CANADIAN AND TODAY’S EXPERIENCE
The re-emergence of the nurse practitioner role is seen as an address to the rising need for a more accessible healthcare. As aforementioned, the role has been highly commended by researches. Nonetheless, the Canadian experience suggests how socio-political factors can hinder its development and lead to its demise. In the following discussions, focus is on the socio-political climate existing in Australia and other countries that affect the development and resurgence of the NP’s in the healthcare system.
Unpolished Policies
As in any other profession, the formalization of any practice through uniform legislation that gives rise to its autonomy and protection is a must. Also, funding is a backbone that supports the sustainability of the practice. In the case of NP’s back in Canada in 1970’s, the lack of these legislative measures and funding proved fatal to the viability of the roles (Brown & Tarlier, 2008).
In Australia, NP’s have been protected by legislative measures (Pearson & Peels, 2002) in NSW, South Australia, Victoria, Capital Territory, and Western Australia (Victorian Government, 1999; Nurses Board of Western Australia, 2003; Nurses and Midwives Board of NSW, 2004; The Australian Capital Territory, 2005; Nurses Board of South Australia, 2006). However, each state has disunified policies that are silent hurdles to the development of NP roles (Chiarella, 2002; Gordon 2005) creating confusion as to the true scope, requirements and responsibility of the practice in Australia.
Also, these legislative policies bring with them the suggestion of autonomy for the practice (Turner, Keyzer, & Rudge, 2007). The NP role itself calls for autonomy as it is structured as a nursing model that is developed by autonomy and accountability where autonomy refers to having a sense of professional identity and an ability to act independently through task mastery and self-efficiency (Australian Nursing and Midwifery Council, 2006). However, in reality, NP’s do not possess this autonomy which the nursing profession intended it to enjoy (Turner, Keyzer, & Rudge, 2007). In a study made by Turner, Keyzer, and Rudge (2007), it has been revealed that NP do not experience autonomy in practice; rather, what occurs is a mere shift in the traditional boundaries of nursing roles as necessitated and dictated by an existing healthcare system’s hierarchy. Thus, the desire for nurses to evolve into this role is low as the NP’s education to function autonomously in advanced and extended roles would not even lead to that autonomous practice after all.
With regards funding, Australia’s policy for financial support for the NP roles has not been clear. With a need for funds for advanced education by NP’s, this seemingly poor effort to sustain the practice financially may prove lethal to the re-birth of the practice (Turner, Keyzer, & Rudge, 2007).
Thus, with these non-uniform policies, false autonomy, and lack of funding for the NP roles, the opportunity for the future of the practice is not clear.
Condemned from the Start
The Canadian experience showed how the NP role has been unsuccessful due to professional and social perceptions that have been derogatory (Brown & Tarlier, 2008). Australian NP’s experience the same.
With feet planted both on the worlds of nursing and medicine (Towers, 2005), the re-emergence of NP roles has not been viewed well and supported by the medical professionals. The Australian Medical Association (AMA) (2005a) has expressed their disagreement with the rise of the practice, claiming that it would lessen the quality of the Australian healthcare system. In addition, AMA (2005b) stated it will be an irresponsible move for the Australian government to resort to NP’s as a substitute for high-quality medical healthcare.
The society and media also plays a role in the derogation of the NP roles. The public views NP’s as just physician replacements (Horrocks, Anderson, & Salisbury, 2002) with the media tagging NP’s as ‘bush doctors’ (Brooker, 2002; Papadakis & Haberfield, 2003). This is problematic for the profession as its identity is not built and recognized, thus undermining NP as an advanced nurse practitioner and an autonomous professional.
Nursing colleagues further depreciates the autonomy and recognition of NP roles. Nurses still have the traditional thinking of nurses as mere follower of orders and that increased responsibility are beyond the scope of nursing (Keyzer, 2001) with others viewing NP’s as just physician extenders (Allen, 1999).
These contexts of professional pride and socially learned thinking that permits just the traditional role of nursing and condemnation of its advanced practices, if not changed, will result to a slow development or even non-progress of NP roles in Australia, as it was back in Canada (Turner, Keyzer, & Rudge, 2007).
The Social Justice Agenda: NP’s ‘Value-Added’ Task
Brown and Tarlier (2008) accounts for the death of NP roles in Canada as also being due to the fact that NP’s were just considered as doctor replacements and that when this deficiency turned into an overflowing of medical professionals, so, too, did the role of NP’s in healthcare became less valued and necessitated. With this, comes their argument that focused on NP’s need to increase social justice participation and political voice noting that this will lead to the NP’s increased valuation in the socio-political context.
Neoliberalism, as it sparked in countries like Australia, has lead to grave health inequities (Laird, 2007). This is because neoliberalism puts more focus on income generation and encourages more cutbacks in public spending such as healthcare and puts more emphasis on self-reliance (Coburn, 2006). With this, patients of NP’s from rural and remote areas are most affected. This calls for NP’s to address “the bigger picture of health disparities and access inequities” (Tarlier, Johnson, & Whyte, 2003, p. 182). NP’s are thereby summoned to place more focus on the collective perspective rather than just the individualism of care (Reimer Kirkham & Browne, 2006).
Yet, NP’s are focused on the biomedical aspects of care disregarding the socio-structural conditions that constrain health and well-being (Bekemeier & Butterfield, 2005). With this, NP’s fail to address the causes of healthcare and cause change in the healthcare of the society, which would have been otherwise essential in the role’s long-term sustenance as it will model NP roles as going beyond physician extender roles and as a more socially responsive nursing practice.
TOWARDS A STEADY DEVELOPMENT: WHAT NEEDS TO BE DONE
NP’s benefit the society and politics by being the cost-effective healthcare delivery response; yet, it is this same socio-political climate that presents hurdles for its development. The learnings we get from the Canadian experience in 1970’s and today’s present socio-political facts point that problems occur in NP development with regards to its legislative policies, autonomy and funding (Brown & Tarlier, 2008). Also, the lack of recognition and respect to the profession by the healthcare professionals, society, and media hinder the growth of the role (Turner, Keyzer, & Rudge, 2007).. Finally, the call for a socially responsive NP role is still to be heeded (Brown & Tarlier, 2008).
Knowing these problems in its development, NP can advance further by addressing these issues. This can be done by a more unified legislation with clear statements on the scope of NP practice and well-established autonomy (Kelly & Matthews, 2001). Funding for NP education and practice must also be looked into by the Australian government since this can lead the spending to a shift to an overall health program for all (Raphael, 2006).
With regards the social and professional recognition, professional organizations must work for the recognition of the practice as a nursing response to contemporary needs for a more accessible healthcare delivery (Pearson & Peels, 2002). The medical professionals must also realize that supporting NP roles in the healthcare system is a must since the need for such a practice is needed by the society that is suffering greatly from health inequalities and delays of healthcare delivery. Meeting these needs should take precedence over professional disputes related to role boundaries (Pearson & Peels, 2002). NP and medical professionals must work collaboratively for the enhancement of healthcare delivery, instead of fighting over professional responsibilities.
In the hope that NP’s could be the voice of social justice, NP’s must not focus solely on biomedical issues of health but must also consider increasing their capacity to address social and health inequities through socially responsive actions (Barker, 2006). Saying such, professional organizations concerned with the education of NP’s must include training on matters of social structures that constrain and improve healthcare delivery.
With these things, the development for NP roles can be seen to be more feasible and sustainable.
CONCLUSION
The resurfacing of NP roles and its birth in Australia points out to the necessity of such an advanced nursing practice in response to current health care and socio-political needs. Yet, as Canada’s and today’s experiences show, some socio-political factors can slow down its development. Among these are the unfurnished legislations that fail to support and protect the practice and socio-political criticisms that condemn and fail to acknowledge the benefits of the practice. Also, the inability of the NP’s to portray a socially responsive role is a hindrance to its development. Addressing these issues by ways that legitimize, support and recognize the practice more and that encourage the NP roles to be more socially reactive must be put to action if the hope for the true resurrection of this nursing practice is to be sustained in the long run. For this, professional organizations are urged to act and NP’s are called upon to deliver not just an individualistic care but a care that addresses the root cause of the problem, that is, social inequalities.
The future is bright for NP’s with opportunities seen and foreseen because of its benefits to health care delivery, particularly to the Australian health care system. With its ability to deliver health care to the deprived and underserved rural and low socio-economic communities, NP’s will gain a continuous interest from the people and government. But if socio-political factors are once again allowed to receive more considerations, then NP roles in Australia can become just another case of a good idea that dies… and when that time comes, Spitzer’s prediction of its non-emergence again may prove to be true after all.
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